It's everyone's responsibility to have "skin in the game"

A message to all physicians from AMA President Cecil B. Wilson, MD.

By Cecil B. Wilson, MDis an internist in private practice in Winter Park, Fla. He served as chair of the AMA Board of Trustees during 2006-07 and was AMA president during 2010-11. Posted May 2, 2011.

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Back in 1998, a long time ago in these instant-messaging days, the American Medical Association House of Delegates adopted a policy that became the cornerstone for our AMA proposal for expanding health insurance coverage and choice -- a preference for individually selected and owned health insurance.

At issue was the growing number of uninsured people -- an estimated 44 million at that time -- and a steady decline in employer-based health insurance. This policy was refined and expanded over the next eight years to include refundable and advanceable tax credits, insurance market reforms and renewed support for health savings accounts.

In 2006 there was still considerable concern about low-risk individuals who were opting out of insurance, driving up costs for those who were insured. So the House of Delegates adopted a final key element that tied together all the other provisions of the AMA proposal for expanding insurance coverage and choice. That element was our individual responsibility policy: that insurance be made available on the open market, that everyone be required to purchase insurance, and that those who cannot afford it have help in doing so.

The following August, we launched our Voice for the Uninsured campaign at the National Press Club in Washington, D.C., and announced the AMA goal to pursue federal legislation that would provide a way to cover the then-uninsured.

Now keep in mind that 2006 was before Barack Obama was a household word, and long before the Patient Protection and Affordable Care Act was even introduced. In fact, the concept of individual responsibility first had appeared in proposals of the late 1980s and early 1990s that were written by organizations such as the conservative Heritage Foundation.

All the elements of the Voice for the Uninsured campaign -- and the policy on individual responsibility -- are still AMA policy today.

Current AMA policy on individual responsibility was reaffirmed by the House of Delegates as recently as June 2010. It contains the following:

  • It does not dictate what specific type of health insurance needs to be purchased, nor from whom it must be purchased.
  • It advocates only that the health insurance purchased must contain, at a minimum, coverage for catastrophic care and preventive services.
  • And for those with incomes below 500% of the federal poverty level, the policy is applicable only if they are provided with subsidies to purchase the insurance.

The health reform law includes a provision similar to the AMA policy on individual responsibility and is scheduled to take effect in 2014. The Congressional Budget Office projects that the coverage provisions in the law, including an individual responsibility provision, will expand coverage to 32 million more Americans by 2016. However, this part of the law is controversial and has been the subject of several constitutional challenges. It is likely that the U.S. Supreme Court will rule on the issue in late 2011 or 2012. Keep in mind, however, that the matter before the courts is the health reform law provision, not the AMA policy on individual responsibility.

Nonetheless, the economic reality is that without some sort of individual responsibility requirement, other parts of the health reform law that are very popular with the public won't work. Poll after poll show that people are pleased and relieved to know that coverage never again will be denied because of existing conditions, and that there are no more lifetime caps on coverage. But if we guarantee that people can get health insurance coverage regardless of their health status, without an individual responsibility requirement, a lot of people won't enroll unless they get sick. And if only predominantly sick people sign up for coverage, premiums will increase to an unaffordable level, pricing health insurance out of the market for many.

The CBO has not scored any alternatives to an individual responsibility requirement that provide remotely comparable gains in insurance coverage. In fact, the CBO estimates that removing the individual responsibility provision in the reform law will cut the number of individuals who become newly insured in half, from 32 million to 16 million. Other analysts have produced projections that show an even more dramatic drop in coverage gains, perhaps to as low as 8 million. Furthermore, most of the remaining coverage gains would be through Medicaid rather than through private health insurance.

The current debate about budget proposals and entitlement program reforms presents even further challenges to Congress, as well as to employers, physicians, other health professionals and patients.

As an American, I am fiercely committed to individual liberty. I also believe it is important that everyone have "skin in the game," so to speak, and be willing to take greater responsibility for his or her health care needs and those of dependents. The reality is that those who voluntarily choose to be uninsured are the reason the rest of us in society have to pay for their care -- involuntarily -- through paying higher premiums, providing uncompensated care and having tax dollars used inefficiently to make that care available where it costs most -- in emergency departments. That is simply not fair, nor is it sustainable.

We all recognize that the debate is not over. However, as the debate continues, we also know of patients who have lost employer-based health insurance. We know others who have lost both jobs and insurance, and we have seen still others who drop coverage to cut costs.

The number of uninsured continues to grow -- today it is nearly 51 million and counting -- along with the unfunded demands for health care that our population clearly desires. The AMA plan for expanding insurance coverage and choice, including the current policy on individual responsibility, is one solution for addressing these needs and challenges.

Cecil B. Wilson, MD is an internist in private practice in Winter Park, Fla. He served as chair of the AMA Board of Trustees during 2006-07 and was AMA president during 2010-11.

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